Difficult Encounters with Parents
Barbara Korsch
I. Description of the problem. No honest clinician in pediatrics can claim to love all patients all of the time or to communicate well with everyone who appears in the practice. There are certain names on the day’s schedule that make the clinician’s heart sink and feel fatigued in advance.
II. Factors in difficult encounters. The situations that trigger negative emotions are not the same for every clinician. It is of fundamental importance for each clinician to develop awareness and insight into his or her own individual sensitivities and idiosyncrasies to minimize counterproductive encounters and to develop strategies for assuring his or her own well-being.
A. The clinician-parent relationship. It is too easy to blame the parent: “The mother was a poor historian” or “She was ignorant, opinionated, and uncooperative.” Unflattering labels are often used to take the onus and the blame off the clinician. If it were entirely the parent’s “fault” that the medical encounter was difficult, there would be no way of mending the relationship. It is more productive for the clinician to realize that a ruptured relationship usually involves both sides. Knowledge, critical self-awareness, and an explicit focus of interest on the communication process and where it went wrong are helpful in this regard.
B. Ambiguity. Clinicians are trained to solve problems and finish tasks. They want diseases that can be named (labeling is one approach to mastery) and symptoms that can be cured. Yet patients’ problems often defy simple solutions. A common reason for difficult encounters lies in the clinician’s (or parents’) discomfort with this ambiguity. Patients with symptoms that do not point to a known disease entity are annoying and frustrating.
C. The overanxious parent. In pediatrics, the parent who recites the child’s complaints in an overanxious and overemotional manner is judged the equivalent of the hypochondriac in adult practice. He or she is equally unpopular and frequently given short shrift, although sympathetic listening to the concerns might reveal significant issues underlying the emotionality. Concluding that “it is the parent who is the problem” and not the child, too often does not lead to problem recognition, empathy, and sympathetic treatment.
D. Slow treatment response. Just as clinicians thrive on the instant gratification of a patient’s getting well quickly, so too are they annoyed by patients who do not respond to treatment. Blaming the patient for a poor response to treatment (even unconsciously) impedes the collaboration with the family. The clinician needs to join the family and patient in facing their common disappointments: “I know you had hoped to see him better by now. So did I. But we will have to be patient a little longer. We do know we are on the right track.”
E. Clinician limitations. All clinicians encounter certain issues, which lead them to communicate less effectively because of special sensitivities. There may be something in the parent’s personality or in the presenting illness of the child that touches a sensitive nerve in the clinician. This often leads to overidentification, which interferes with accurate empathy. It is crucial that the physician develops enough awareness of these special vulnerabilities so that they do not interfere with optimal patient care “—physician knows thyself.”
1. A frequent barrier to effective communication lies in the clinician’s difficulty in accepting his or her own limitations. A parent who “shops” for medical care; who quotes other authorities (“When the child next door had the same thing, the doctor gave him antibiotics and he was fine the next day”); who reads independently and forms strong opinions (“I read on the Internet that new medicine A is really more effective”); who challenges directly (“How many children have you raised doctor?” or “How many kids with this condition have you treated?” or “How long have you been in practice?”)— these are all unpopular parents. The reason, often, is that the health professional needs to feel that parents will accept only his or her authority. The idea that a parent might inquire elsewhere, quote information or misinformation from the Internet,
and that there are other valid (and sometimes better) ideas may seem unacceptable. But such paternalism is unjustified in all respects, especially in a therapeutic alliance between clinician and patient’s family.
2. Failure to accept personal limitations in knowledge and competence may lead the clinician to perceive patients as difficult. A simple, “You know, I have not really seen this particular combination of signs and symptoms before. I would like you to see Dr. X who has more experience in this line,” may be an effective approach that relieves clinician stress and parental anxiety.
F. Cultural differences. The clinician’s lack of knowledge about cultural factors that may provoke certain kinds of patient symptoms or behavior can also lead to irritation and impatience. For instance, resistance on the part of certain Latino families to have their daughter’s perineum inspected might be interpreted as ignorance and resistance. The informed clinician understands that the mother’s reluctance is not a personal reaction but is based on the cultural belief that privacy must be protected in young girls at all costs. There are also differences in cultures of medical care and it is increasingly important for the clinician to assess the families’ ideas concerning complementary or alternative medical practices and to include these in the joint decision making.
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